Breastfeeding Medicine

Physicians blogging about breastfeeding

Update: Research studies quantify risks of risk-based language

with 4 comments

Last month, I blogged on my growing discomfort with ‘risk-based language’ to support breastfeeding. I explained that rationale for risk-based language is that

… when we talk about risks of formula, we will motivate mothers to “clamor for help,” and thereby increase breastfeeding rates and improve the health of mothers and babies.

It’s a compelling logical argument. And yet, I’ve been unable to find empirical evidence that it is true. To generate that evidence, we’d need to compare outcomes among mothers and babies counseled that formula increase risk with outcomes among those told that breastfeeding improves health and wellbeing. To my knowledge – and please let me know if there is a peer-reviewed study out there! – such a study has not been done.

In face, such a study has been done, by Lora Ebert Wallace and Erin N. Taylor, in the departments of Sociology and Anthropology and of Political Science at Western Illinois University. When they contacted me, they reminded me that I’ve blogged previously about their work on “shame” and “guilt” in discussions about breastfeeding. And – spoiler alert – they found that risk-based language did not increase breastfeeding intentions; rather, risk-based language reduced trust in the information provided.

Wallace and Taylor have conducted two studies assessing the impact of risk vs. benefit-based language on feeding intentions. In their first study, published in 2011, they enrolled 434 undergraduate students at Western Illinois University. Students provided demographic information and were randomly assigned to read a page of information about breastfeeding, framed as either “benefits of breastfeeding” or “risks of formula.” Here’s the first paragraph for the two texts:

Benefits of Breastfeeding

Breastfeeding is universally endorsed by the world’s health and scientific organizations as the best way of feeding infants. Years of research have shed light on the vast array of benefits not only for children but also for mothers and society.

Risks of Formula Feeding

Formula-feeding is universally denounced by the world’s health and scientific organizations as the worst way of feeding infants. Years of research have shed light on the vast array of harm from formula-feeding not only for children but also for mothers and society.

In this first study, the researchers also varied the logo on the text among three conditions:

  1. NCIH National Center for Infant Health
  2. NBAC National Breastfeeding Advocacy Coalition
  3. No professional logo

Participants read the text, and then answered a series of questions regarding their intentions to breastfeed, feed breastmilk from a bottle, and/or formula feed. They also answered questions regarding whether the text “was clear, accurate, helpful to new parents, the degree to which they trusted the information, and the degree to which their answers regarding feeding intentionality were based on the text.”

The researchers found that whether participants read risk-based or benefits-based texts had no impact on feeding intentions. However, participants rated the risk-based language more negatively. Interestingly, they also rated the texts with the National Breastfeeding Advocacy Coalition logo more negatively. The authors concluded,

This suggests that respondents overall disliked the risk text, but also disdained the text more readily when a breastfeeding advocacy logo was attached, regardless of risk/benefit condition.

For their second study, Wallace and Taylor conducted a similar experiment among 270 pregnant women recruited from online message boards. The same texts were used, but no logo was placed on the documents. More than 80% of participants were white, and more than half had a 4-year college degree or higher.  As part of the survey, women were asked whether they had undergone any breast modification, defined as augmentation, reduction, or nipple piercing.

The findings were strikingly similar to the college student study: feeding intentions were similar, regardless of whether risk- or benefit-based language was used, but participants rated the risk-based language more negatively, independent of age, number of children, education, income, or race.  Interestingly, women who had undergone breast modification rated the risk-based language more negatively than those who had not.

The bottom line: in these two studies, risk-based language had no impact on feeding intentions, but was rated as less useful and trustworthy than benefit-based language. The authors conclude:

We call for breastfeeding advocacy and health promotion strategies that respect the autonomy and intelligence of mothers. A woman-centered approach trusts mothers to do the best they can for their children in the social and economic contexts in which they parent. Mothers’ rejection of risk language breastfeeding advocacy demonstrates the ineffectiveness of advocacy methods that do not include women as equal partners with health advocates.

As with all studies, there are limitations. The wording on the “Risks of Formula Feeding” text was strident, and the negative ratings might not arise in a more nuanced, but nevertheless risk-based, educational pamphlet. Moreover, future research needs to consider the impact of risk-based language among women of color and among low-income women, whose social constraints differ from white middle-class women.


However, for now, the existing evidence suggests that both college students and pregnant women are no more likely to intend to breastfeed after reading about  “risks of formula” than “benefits of bresatfeeding.” However, they ARE more likely to distrust information framed as “risks of formula” – and more likely to distrust information labeled as “breastfeeding advocacy.”

That’s sobering information for those of us want to encourage women to initiate and sustain breastfeeding. These data suggest that a “risk of formula” message may undermine women’s trust in the messenger, reducing our ability to provide concrete support and assistance.

There might, indeed, be risks of risk-based language.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician and breastfeeding researcher. She is an associate professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and Distinguished Scholar of Infant and Young Child Feeding at the Gillings School of Global Public Health. You can follow her on Twitter at @astuebe.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.




Written by astuebe

May 4, 2016 at 11:23 am

4 Responses

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  1. In our breastfeeding-phobic society, I am not surprised that stridently phrased articles from BF promotion organisations are unpopular. I’d also query the words used – do health organisations “denounce” artificial breastmilk substitute? Most are very careful to support mothers in those situations IME! Also, formula isn’t normally described as the “worst” way of feeding babies – there are lots of worse ways of feeding than using a commercially prepared artificial breastmilk substitute. In other words: I don’t think it’s a fair trial.

    Breastfeeding in a phobic and anti-maternal society will always be a subversive choice. I’m not surprised that college students and pregnant women are nervous about strong language.

    I remain convinced that the words “significance of breastfeeding” and “importance of breastfeeding” are ways to convey the multitude of reasons to breastfeed, without setting up a comparison between breastfeeding and formula feeding. I want to step away from the mummy wars, not inflame them.

    Melanie F

    May 4, 2016 at 2:28 pm

  2. I think what needs to happen though is the study of using risk language by the provider. Not on the Internet not I’m posters are billboards. But instead just like they do with circumcision today ms. so-and-so there is a risk of increased ear infections obesity and –_____. Do you plan to breast-feed or formula feed? And just like with the circumcision question it should be asked numerous times during pregnancy


    May 4, 2016 at 5:02 pm

  3. Any study done on education to health care provider using “benefits” language or using “importance of breastfeeding and may be risks from not breastfeeding” and the intention of those providers to to discuss/support breastfeeding with their clients? Issue 43 Sept 2011 may be of interest about providing information for thought and discussion rather than trying to persuade.

    Genevieve Becker

    May 5, 2016 at 3:05 am

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